Based on their conversation, the Heart Failure Nurse completes an anticipatory care plan for Mina, with a DNACPR form. The format for anticipatory care plans may vary slightly, depending on the health board or clinical area. Useful suggestions on how to develop a plan can be found at:
Good Life, Good Death, Good Grief – Making an Anticipatory Care Plan
NHS Highland Anticipatory Care Patient Alert (ACPA) Form Pack (PDF)
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Mina agrees that she is happy with the plan. She is given a copy and a further copy is given to her GP.
The Heart Failure Nurse visits Mina
Redtown Health Centre
Ben Wyvis Close
Redtown
dr0234 56134
ANTICIPATORY CARE PLAN
PATIENT INFORMATION
Patient name: Mina McGee
Title: Mrs
NHS Number: ********
Date of birth: 8 May 1935
Address: Rowan Cottage, Redbrick Road, near Redtown
Post code: **** ***
Is the patient a nursing/care home resident? No
Contact details: 0234 72195
Key safe door access code: ******
Named accountable GP: Dr D Johnstone
Care coordinator (if appropriate):
Other named professionals (e.g. care coordinator, other healthcare professionals or social worker) involved in patient’s care, if appropriate (include contact details where possible):
Peter Thomas
Heart Failure Nurse
Redtown Health Centre
07765 8112233
Has information been shared on the patient’s behalf? No If yes, by whom:
(Only applicable where the patient does not have the capacity to make this decision)
Patient (or allowed individual) consent to share information:
- with other healthcare professionals involved in the patient’s care, e.g. carer, OOH, etc.:
Yes - with the multi-disciplinary team
Yes
NEXT OF KIN / CARER / RESPONSIBLE ADULTS INFORMATION
Name: Alistair McGee (Power of Attorney)
Title: Mr
Address (if different from above): Flat 65, Red Road Lane, Glasgow
Post code: **** ***
Contact details: 0235 77854
Relationship: Son
Additional emergency contact (if appropriate):
Name: Susan Brown
Contact details: 0234 3564
Relationship: Minister
PATIENT’S MEDICAL INFORMATION
- Heart Failure (secondary to aortic stenosis)
- COPD
- Renal problems
Significant past medical history:
- past history of depression
- 3 hospital admissions this year
- 4/4/2019 (4 days)
- 11/7/2019 (3 days)
- 8/11/2019 (5 days)
Current medication:
WILL SEND THIS ACROSS
Date of planned review of medications: Medication review carried out 13/1/2020
Allergies: none known
KEY ACTION POINTS
- Does not want any invasive treatment
- DNACPR discussed and form completed
- Son has power of attorney for all matters
- Would like end-of-life care to be provided in hospice, if husband still alive. At home, if husband dies before her.
OTHER RELEVANT INFORMATION
Informal carer for husband, who has advanced dementia.
Carers visit daily to provided personal care and support for meals.
Anticipatory care plan agreed: Yes
Anticipatory drugs supplied: N/A
Emergency care and treatment discussed: Yes
DNACPR form completed and attached
Date of assessment: 18/1/2019
Date of review: 18/4/2019
Any special communication considerations (e.g. patient is deaf or language communication differences):
None
Any special physical or medical considerations (e.g. specific postural or support needs or information about medical condition – patient needs at least x mgs of drug before it works, etc.):
None
SIGNATORIES
Patient signature:
Date:
Carer (if applicable) signature:
Date:
Named accountable GP signature:
Date:
Care coordinator signature (if applicable):
Date:
Page last reviewed: 28 Sep 2020
